Guide By Dr. Chandralekha B Dr. Nilofer Prof. & HOD PG Student Dr. Roopa Tubaki Sr.

Lecturer Vydehi Institute Of Dental Sciences

Contents

Introduction Classification Advantages Appliances In Detail. Herbst Appliance. Modification Of Herbst Appliance. Jasper Jumper . The MARS device. The Mandibular Protraction Devices. The Amoric Torsion Coils. The Scandee Tubular Jumper. The Cantilevered Bite Jumper The IST device.

The Adjustable bite corrector. The Churro Jumper . The Eureka Spring. The SAIF spring. The Universal Bite Jumper. The Ritto Spring. The Magnetic Telescopic Device. The Twin Force Bite Corrector. Alpern Class II Closers.

 The Mandibular Correctors.

The Horizontal Anterior Positioning Appliance. The Mandibular Anterior Repositioning appliance. The Biopedic Appliance. The Klapper Superspring II. The FORSUS Fatigue Resistance Device. Hybrid Appliance. Conclusion

Introduction
Definition :

A functional appliance by definition is one that changes the posture of the mandible, holding it open or open and forward, stretches the soft tissues and changes the tone of the muscles, creating pressures which are transmitted to the dental and skeletal structures, moving teeth and modifying growth.

 Functional Appliances have been in existence for over

85 years . The first of which was given by Emil Herbst however these were not well accepted at that time till later when these were reintroduced by Hans Pancherz.

 Removable functional appliances are normally very

large in size have unstable fixation cause discomfort lack tactile sensibility exert pressure on the mucous (encouraging gingivitis), reduce space for the tongue cause difficulties in deglutition and speech affect aesthetic appearance.

 The alteration in the mandibular posture creates

added difficulties. These adverse effects make the adaptation and acceptance of these appliances more difficult.

[Ref : Attitudes to orthodontic treatment. Oliver and Knappman British Journal of Orthodontics 1985; 12:17988. Ngan P., Kess B., Wilson S. Perception of discomfort by patients undergoing orthodontic treatment. Am. J. Orthod. Dent. Orthop. 1989; 96:47-53.]

 Fixed functional appliances are normally known as

"non-compliance Class II correctors" This gives a false idea about the co-operation necessary during treatment. In reality, when we compare them to removable appliances, we can clearly recognize fixed appliances as non-compliance devices. However, for treatment to be successful, good cooperation is always necessary, especially if skeletal modifications instead of dentoalveolar compensation are desired.

Advantages
Fixed functional systems have some advantages over

removable systems. 1. They are designed to be used 24 hours a day, which means that there is a continuous stimulus for mandibular growth. 2. They are smaller in size permitting better adaptation to functions such as a mastication, swallowing, speech and breathing. 3. Fixed functional appliances are usually described as noncompliance Class II devices, which are able to treat Class II malocclusions successfully, while reducing the need for patient co-operation and overall treatment time. It is possible to treat this type of malocclusion with minimal effort.

4. Short treatment time due to the above 6-8 mths. 5. Just as the name implies, what distinguishes them

from removable appliances is that it is impossible for the patient to remove them. What we have therefore, is an appliance that allows greater control by the orthodontist. 6. Leads to the development of a New Morphogenetic pattern. 7. Has other actions also such as molar distalizing effect, correction of midlines, headgear effect etc.

Disadvantages
The main disadvantage that may be encountered is

dental movement that takes place during treatment. In certain FFAs components have an increased tendency to fracture. The size of different components may have to be altered as the patient may outgrow it or the desired effect may be achieved. The above factors add to the cost.

According To Type Of Forces Produced : Appliances Producing Pushing Force Appliances Producing Pulling Force.

These appliances deliver a pushing force vector forcing the attachment points of the appliance away from one another . e.g Herbst App.

These appliances create a pulling force vector between the points of attachment. e.G The SAIF Spring.

II Depending Upon flexibility : Rigid Fixed Functional Appliance { RFFA}.

RFFAs do not easily fracture but neither do they have elasticity or flexibility. After fitting and activation they do not allow the patient to close in centric relation. This means that the mandible is in a forward position 24 hours a day creating greater stimulus for mandibular growth than with FFFAs. Used in Class II Div 1 & 2, And in Class III

Flexible Fixed Functional Appliance { FFFA }

The type of the force exercised by this is continuous and elastic in nature . These Fracture /Get fatigued easily. FFFAs are not recommended in mixed dentition, especially late mixed dentition to avoid unwanted dental movements.

Types
RFFA with Pushing Forces: 1. Herbst Appliance and its modifications. 2. Mandibular advancement repositioning splint. 3. Mandibular protraction appliance. 4. Eureka Spring. 5. Universal Bite Jumper. 6. Biopedic. 7. Mandibular anterior repositioning appliance . 8. Functional Mandibular Advancer.
FFFA with Pushing Forces 1.
2.

Jasper Jumper.
The Bite Fixer .

3. 4. 5. 6. 7. 8. 9.
10. 11. 12. 13.
14. 15.

Churro Jumper. The Amoric Torsion Coils. Adjustable Bite Corrector. Universal Bite Jumper. Klapper Super Spring II. Forsus. The Scandee Tubular Bite Jumper.
The Magnetic Telescopic Device. The Mandibular Protraction Appliance. The BioPedic Appliance The Mandibular Anterior Repositioning Appliance
The IST Appliance The Ritto Appliance

 In spite of considerable research and debate, the precise

mode of action of functional appliances remains obscure.

Many theories seem to be propounded which are

mentioned as follows and can act singularly or in combinationthese theories are common to both fixed and removable myofunctional appliances.. They are: 1. Dentalveolar changes. 2. Redirection Of Condylar growth. 3. Deflection Of Ramal Form. 4. Horizontal Expression Of Mandibular Growth.

5. Changes in neuromuscular anatomy and function.

Adaptive changes in glenoid fossa location Leading to anterior repositioning of the mandible.
6.

[Ref : The Influence Of Functional Appliance Therapy On Glenoid Fossa Remodelling. DG Woodside,a Metaxas, G Altuna AJODO 1987 ; Vol 82 : Pg 181 -198 ]

Herbst Appliance
Introduced in the 5th International Dental Congress in

Berlin in the year 1909 by Emil Herbst. Called it the Fixed Bite Jumping Device or Scharnier or Joint.
In 1934 he published 3 articles in the journal

Zahnarztliche Rundschau on his experiences with the appliance. In the same journal his work was criticised by Martin Schwarz in 2 articles.

 According to Schwarz, the Herbst appliance could result in

an overload of the anchorage teeth with periodontal damage as a consequence. This claim has, however, been disproved in a recent thesis of Pietz(2000).

However it was to be found that Herbst was much ahead of

his time. His contributions were many 90% of what is known today. His main contribution to modern orthodontics was, however, the development of the Okklusionsscharnier or Retentionsscharnier (Herbst appliance)

[ Ref : History, Background, and Development of the

Herbst Appliance

Hans Pancherz Semin Orthod 2003;9:3-11.]

The Original Herbst Appliance

 In 1977 Hans Pancherz reinstated clinical trials.

Reintroduced by in 1979. In his article History, Background, and Development of the Herbst Appliance

Hans Pancherz (Semin Orthod 2003;9:3-11.) has beautifully described the history development and background of this appliance with useful clinical information and a background on Dr. Emil Herbst.

 Advantages of The Herbst Appliance over Activator,

Bionator, And Frankel 1. It is Fixed to the teeth. 2. Patient compliance not at all required for correct functioning. 3. Works 24 hrs a day. 4. Treatment time is shortened.

The Basic Design Of Herbst

The Herbst appliance is a fixed bite-jumping device for

the treatment of skeletal Class II malocclusions. It can be compared with an artificial joint working between the maxilla and mandible. A bilateral telescope mechanism keeps the mandible in an anterior-forced position during all mandibular functions such as speech, chewing, biting, and swallowing.

 The telescope mechanism (tube and plunger) is

attached to orthodontic bands, crowns, or splints. The tube is positioned in the maxillary first molar region and the plunger in the mandibular first premolar region. The telescopes allow mandibular opening and closing movements and when constructed properly lateral jaw movements are also possible.

 Originally the telescopes were curved . Made Of German Silver / Gold. Gold if worn more

than 6 months Bands or Crowns /Caps were used on Abutment teeth. Originally placed upside down with plunger on maxillary molar. No opening at the back.

The telescopes allow mandibular opening and closing movements and when constructed properly lateral jaw movements are also possible.

 Each telescope consists of a tube, a plunger, 2

pivots (axle), and two locking screws that prevent the telescoping parts from slipping past the pivots.

 Length of the plunger should be kept at a maximum to

prevent it from disengaging from the tube.

A large interpivot distance prevents the plunger from

slipping out of the tube when the mouth is opened wide.

A plunger too far behind the tube can injure the buccal

mucosa.
If plunger disengages from the tube on mouth

opening, it may get stuck in the tube opening on subsequent mouth closure and damage the appliance.

Anchorage Forms Of The Herbst..

Deserves special attention.
Because of anchorage loss, maxillary and mandibular tooth movements cannot be avoided.

Several anchorage systems have been developed to control unwanted tooth movements

From 1909 - 1934

The standard anchorage system used by Herbst: Crowns or caps were placed on the maxillary permanent

first molars and mandibular first premolars (sometimes canines). The crowns/caps were joined by wires that run along the palatal surfaces of the upper teeth and the lingual surfaces of the lower teeth.

 If second permanent molars have not erupted then Herbst advised to anchor the appliance more firmly by placing bands on the canines, which were soldered to the palatal arch wire as were the upper molars.
Alternative to bands on the upper canines, a thin gold wire was placed on the labial surfaces of the

upper incisors and soldered to the palatal arch wire.

 When using the Herbst

appliance in the early mixed dentition, Herbst had the following solution:
In the maxilla, the

permanent central incisors were used for anchorage instead of the cuspids.
In the mandible, crowns

were placed on the first permanent molars and bands on the 4 permanent incisors.

Late mixed dentition anchorage

Canines are used as

anchorage teeth instead of incisors. Buccal mucosa at the corner of the mouth is prone to ulceration when mandibular canine is used as an abutment tooth for the plunger.

 Herbst and others realized the necessity of incorporating as many teeth as possible for anchorage to avoid unwanted side effects. Schwarz( 1934): Most teeth in the maxilla and mandible were interconnected by labial as well as lingual arch wires this was called Block anchorage.

1979 Onwards
Pancherz originally used a banded type of Herbst

appliance.Individually made stainless steel bands of a thick material (0.15- 0.18mm) were used.
1. 2. 3. 4.

Simple anchorage system Increased anchorage system Total anchorage system Cantilever Herbst

 Maxilla- Bands are placed

on 1st permanent molars and first premolars. Joined on each side by sectional arch wires.
Mandible- Premolars are

banded and connected with a lingual sectional arch.

 Disadvantages:
Space opening distal to maxillary canines Excessive intrusion of 1st permanent molars.

Buccal tipping of 1st premolars

Large proclination of lower anteriors
Thus, anchorage had to be increased by incorporating

more teeth.

Increased anchorage system

Maxillary and mandibular front teeth were incorporated in the anchorage system by labial sectional arch wires. Mandibular lingual arch wire extended to 1st

permanent molars.
Since 1995, cast chrome-cobalt splints are used routinely.

 The splints cover all buccal teeth in the maxillary and

mandibular arches and also the mandibular canines.

Chair time is short and the appliance is strong, hygienic,

and causes few clinical problems.

In the early 1980s, Howe and McNamara developed the acrylic splint Herbst appliance which is used both.as a fixed (bonded to the teeth) and removable appliance. recommended.

However, use of the Herbst as a removable device is not

 The Cantilever Herbst appliance design is mainly

indicated in the early mixed dentition before the eruption of the mandibular permanent canines and first premolars.
The lower part has heavy metal extension arms that are

soldered to the permanent first molar crowns.

The arms extend anteriorly, lateral to the dentition and

terminates in the premolar region in which the telescoping axles are soldered. Have occlusal rests incorporated.

 Support wires attached to the cantilever arms, working as

occlusal rests on the first or second deciduous molars are important.

Without these rests (as seen in earlier designs of this

appliance), the vertical force vector of the telescopes acting as lever arms will result in uncontrolled mesial tipping and extrusion (extraction) of the molar teeth.
But the anchorage control of the mandibular molars with

the cantilevers (even when using occlusal rests on the deciduous molars) is questionable.

 None of the anchorage systems used in Herbst

treatment could prevent anterior movement of the mandibular incisors and molars. ( Pancherz and Hansen1988) Lower anchorage is a problem difficult to master in Herbst treatment. Some factors associated with anchor loss can be :
Severity of A-P interarch discrepancy Amount of bite jumping at the start of treatment.

Treatment Effects
Sagittal Skeletal Dental
Vertical Skeletal Dental

Sagittal Changes
1.Restrains maxillary growth and decrease of SNA angle.
2. Increases mandibular length

(Pancherz 1979, 1981, 1982). This finding is in agreement with several bite jumping experiments in growing monkeys (Stockli and Willert 1971, McNamara 1972, 1973, 1975) and rats (Petrovic and Stutzman 1969).

 Evidence of temporomandibular growth

adaptations in Herbst treatment:

Three adaptive processes in the TMJ are thought to contribute to the changes of mandibular position.

1) Condylar remodeling. (2)Glenoid fossa remodeling; (3) Condylar position changes within the fossa.

Animal Studies
Peterson and McNamara (semin orthodontics

2003) :
Evaluated histologically the TMJ, glenoid fossa, and

the posterior border of the mandible in juvenile Rhesus monkeys whose mandibles had been positioned forward with a Herbst appliance

 Condyle remodelling :

Especially in the Posterosuperior region of the condyle. Glenoid Fossa Remodelling : Significant deposition of new bone on the anterior surface of the postglenoid spine occurred, indicating an anterior repositioning of the glenoid fossa. Similar to (Breitner 1930,33).
Significant bone resorption on the posterior surface of

the postglenoid spine was noted

Significant bony apposition on the posterior border of the mandibular ramus was evident during early experimental periods. No gross or microscopic pathological changes were noted in TMJ of the juvenile Rhesus monkey.

Clinical Studies
Have provided radiographic evidence of TMJ growth

adaptation in Herbst treatment.

Paulsen et al (1995) :
Analysed TMJ changes in a single case of Herbst treatment in

late puberty using CT scanning and OPG. Three months after insertion of the appliance CT-scanning and OPGs of the TMJ revealed new bone formation as a double contour in the articular fossa and on the posterior part of the condylar process as a result of adaptive bone remodeling.

 Ruf and Pancherz (1998, 1999):

Analysed three possible adaptive TMJ growth processes contributing to increase in mandibular prognathism accomplished by Herbst treatment : Condylar remodeling Glenoid fossa remodeling Condyle fossa relationship changes. Aidar, Abrahao ,Yamashita , Dominguez (AJO 2006) assesed the TMJ disc position with MRI after 12 month period of herbst appliance therapy in 20 ClassII div1 patients. They found mild changes in position of the disc with slight tendency towards retrusion due to mandibular advancement which returned to normal after appliance removal. These changes were in the normal phsiological limits as evaluated in short term.

Dental Changes
Basically a result of anchorage loss in the two dental arches.

Mandibular teeth are moved anteriorly. Proclination of lower anteriors. Mandibular incisors proclined on an average of 6.6 during 6 months (Pancherz, 1985). In 24 class II subjects treated with the Herbst appliance (Hansen et al, 1997), the proclination during treatment was 11. 2. Lower Incisor Proclination and recession.
1.

Large amount of lower incisor proclination during Herbst treatment could be thought to cause break down of the labial gingival attachment & create gingival recessions

 Maxillary Molars are driven distally

The effect of the Herbst appliance on maxillary molar teeth is essentially comparable with that of a high pull headgear (Pancherz, AnechusPancherz, 1993). The teeth are both distalized and intruded. Normally, the dental changes occurring during Herbst appliance treatment would not be desirable. Distal tooth movements in maxillary buccal segments could however, be desirable in cases with anterior crowding

 Mesial Movement Of Lower Molars.

Sagittal Dental Arch Relationship Overjet is reduced in all patients during treatment by increase in mandibular length and mesial movement (proclination) of the mandibular incisors. Class II molar correction by increase in mandibular length, distal movement of maxillary molars and mesial movement of the mandibular molars.
Herbst appliance corrects or overcorrects both molar & canine sagittal

relation in most of the cases. However treatment is more effective in the molar than in the canine region

 Arch Perimeter

Because of the distalizing forces of the telescope mechanism of the Herbst appliance on the upper 1st molars and the anteriorly directed forces on the lower front teeth, the maxillary and mandibular arch perimeters increase during treatment. (Hansen et al, 1995) Arch perimeter changes are, however, of a

temporary nature because settling of the teeth during the immediate post treatment period.

 Arch Width

Hansen et al (1995) : During treatment the maxillary and mandibular dental arches expand laterally in both canine and molar areas. The expansion is more marked in the maxilla than in the mandible.

Vertical Changes
Dental

In Class II malocclusions with deep bites, overbite

may be reduced significantly by Herbst therapy (Pancherz, 1982, 1985) an average of 3.0mm (55%) during 6 months of treatment.
Overbite reduction is primarily accomplished by intrusion of lower incisors and enhanced eruption of lower molars.

 Part of the registered changes in the vertical position of the

mandibular incisors results from proclination of these teeth.

Because of vertical dental changes, maxillary and

mandibular occlusal planes tip down.

 Skeletal Increase in lower anterior facial height (LAFH) due to over eruption of lower posterior teeth.

Increase in gonial angle this may be due to a more sagittaly directed growth of the condyle or it may result from resorptive bone changes in the gonion region, probably as a consequence of an altered muscle function during bite jumping
(Pancherz & Littman, 1989)

 The following changes contribute to Herbst appliance correction of class II malocclusion.

Stimulation of mandibular growth. Inhibition of maxillary growth (a less important change) Distal movement of upper dentition Mesial movement of lower dentition (proclination of the incisors

Indications For Treatment

Growing individuals ( Pancherz Ajo Do 1985). Should not be used in non growing subjects
1. 2. 3.

because. Skeletal alterations will be minimal. More of dentoalveolar changes. Increase risk of developing dual bite.

 Postadolescent patients:
Who have passed the maximum pubertal growth spurt and

have still some growth potential left, treatment with the Herbst appliance is indicated as it can be finished within 6 to 8 months.

Mouth breathers: Nasal airway obstructions can make

the proper use of removable appliances difficult or impossible but doesnt interfere with herbst. without any assistance from the patient.

Uncooperative patients: It is fixed to the teeth Patients who do not respond to removable appliances.

 For mandibular fracture (particularly ramus) patients

after surgery For prevention of bruxism For diseases of the TMJ

Treatment Timing
Most favorable time to treat the patients with the Herbst appliance is at the peak of pubertal growth spurt Pancherz, Hagg, 1985.
Pancherz & Hagg (1988): Indicated that the patients

treated at the initial closure of the middle phalanx of the third finger (MP3-FG) had the greatest amount of condylar growth. Because mandibular growth stimulation using the herbst appliance is also possible in post adolescent young adult subjects, a new concept of Class II therapy is proposed in which the Herbst appliance is used as an alternative to orthognathic surgery in Class II subjects.

 Perfect end result cannot be obtained exclusively with Herbst. Class II cases cannot be treated to a perfect end result with the Herbst appliance exclusively. Many cases will require a subsequent dental-alignment treatment phase with a multibracket appliance.

Thus, treatment of a Class II, Division 1 malocclusion will usually occur in two steps STEP 1. ORTHOPEDIC PHASE. The sagittal jaw base relationship is normalized and the Class II malocclusion is transferred to a Class I malocclusion by means of the Herbst appliance.
STEP 2. ORTHODONTIC PHASE. Tooth

irregularities and arch discrepancy problems are treated with a multibracket appliance (with or without extractions of teeth).

 A Class II, Division 2 malocclusion may require a three-step

treatment approach

STEP 1. ORTHODONTIC PHASE. Alignment of the

anterior maxillary teeth by means of a multibracket orthodontic appliance. jaw base relationships and transformation of the Class II malocclusion into a Class I malocclusion by means of the Herbst appliance.

STEP 2. ORTHOPEDIC PHASE. Normalization of sagittal

STEP 3. ORTHODONTIC PHASE. Tooth irregularities and

arch-discrepancy problems are treated with a multibracket appliance (with or without extractions of teeth).

 So the ideal patient for treatment with the Herbst

appliance has the following characteristics: Skeletal morphology.

Retrognathic mandible. Small mandibular plane angle indicating an anterior

growth direction of the mandible. (A favorable growth pattern both facilitates treatment and counteracts post treatment relapse.) Normal or reduced lower facial height.

l
Dental morphology:
Class II dental arch relationship with increased overjet

and normal or increased overbite (open bite cases not suitable for Herbst appliance). Maxillary and mandibular teeth well aligned and the two dental arches fitting each other in normal sagittal position

Maturation:
Treatment during pubertal growth spurt.

Types Of Herbst Appliance

Original Design Maintained With A Few

Modifications. Type I Type II Type III Type IV

Type I
Type I is characterized by a fixing system to the crowns

or bands through the use of screws. This is the most common form. It is necessary to weld the axles to the bands or crowns and then fix the tubes and plungers with the screws

Type II
Type II has a fixing system that fits directly onto the

archwires through the use of screws. This method of application has the disadvantage of causing constant fractures in the archwires. The lack of flexibility together with the difficulty in lateral movements and the stress placed on the archwires through activation causes fractures, especially in the lower arch

Type IV
Type IV has a fixation system with a ball attachment, which allows greater flexibility and freedom of mandibular movement.
A disadvantage in relation to other similar appliances is the fact that it needs brakes to stabilize the joint. These brakes are small and

sometime difficult to fit.

 Class II malocclusions

who have narrow maxillary arches, Herbst appliance with 1. A quad helix lingual arch wire or 2. Rapid palatal expansion device to the upper premolar and molar bands or to the splint.

 The Cast Splint Herbst

Appliance Developed By Pancherz. The bands are replaced by splints, cast from cobaltchromium alloy and cemented to the teeth with GIC. The upper and lower front teeth are incorporated into the anchorage through the addition of sectional arch wires. The cast splint appliance ensures a precise fit on the teeth is strong and hygienic saves chair time Causes very few clinical problems

Herbst With Stainless Steel Crowns

Norris M. Langford

(1982 ) suggested using stainless

steel crowns on the upper first molar and the lower first premolar and canine for the Herbst appliance which are superior to banding, in that they are resistant to breakage and becoming loose.

Modifications

the substitution of stainless steel crowns for bands. the elimination of the stabilizing bar.

The Bonded H

The Bonded Herbst Appliance

The bonded Herbst appliance eventually evolved into

the acrylic splint Herbst appliance (McNamara, 1988; McNamara and Howe 1988).

The acrylic splint Herbst appliance is composed of a wire framework over which has been adapted, 2.5-3.0 mm thick splint Bioacryl, using a thermal pressure machine

 By substituting an acrylic splint

for the stainless steel bands of the earlier appliance, the Herbst mechanism can be attached to both maxillary and mandibular arches using bonding procedures

 The maxillary splint covers all

available maxillary teeth with exception of the central and lateral incisors
The occlusal thickness of the

maxillary splint is kept to a minimum, so that the cusps of the posterior teeth perforate the splint

 These perforated

openings permit the placement of the nylon tip of a posterior bandremoving plier against the cusps.

Disadvantage of Banded Herbst:

I)

II)

III)

IV)

Repeated breakage and loosening of the appliance occurs, especially in the lower bicuspid band area. Rapid intrusion of the mandibular first bicuspids which though temporary, partially deactivates the appliance. As the bicuspids are depressed, the lingual arch is also depressed, resulting in impingement on the lingual gingiva. Possibility of incisal tooth fracture.

Headgear Herbst Appliance

Weislander 1984. Suggested the use of headgear Herbst appliance in the treatment of large sagittal discrepancies between the maxilla and mandible in early mixed dentition. The Herbst appliance consisted of a cast of vitallium bonded to the lower arch and with bands on the upper first permanent molars. The upper bands were united with a palatal bar and connected to the lower splint with the Herbst telescopic arms.

 He concluded that a short

period of interceptive orthopedic treatment in the very early mixed dentition may be indicated to correct skeletal deviation and establish a normal relationship between maxilla and mandible.

Cantilevered Herbst Appliance

Larry W White 1994.
Buccal cantilever wire is made by doubling .045" wire and

soldering the two strands together.

 This design is

particularly useful when mandibular bicuspids are absent or the primary molars cannot withstand functional forces.

Modified Herbst Appliance For Mixed Dentition.

Introduced by Philip Goodman and Paul Mc Kenna, 1985
They stated the middle phalanx development may, indicate

optimal treatment timing, but the patients bicuspids are not erupted enough to receive either bands or crown.

Also they encountered a modification where stainless steel

crowns are fitted on the upper first permanent molars and bands on the lower first molars and incisors.

 The deciduous first and second molars are free to exfoliate

through the framework

 If the patient is uncomfortable

with much mandibular advancement, have the patient retrude the mandible until the discomfort disappears. The telescopic part of the appliance can be advanced again in six to eight weeks using washers or metal sleeves.

The Emden Herbst Appliance

Introduced by Tarek Zreik, 1994 to overcome breakage

problems, he had with the Herbst appliance.

This modification makes the Herbst more durable, simple

and hygienic. The Herbst mechanism is attached to stainless steel crowns on the maxillary first permanent molars and to the lower arch through a removable acrylic splint. Double buccal tubes on the stainless steel crowns can hold utility, sectional, or continuous archwires

 Advantages of the EMBDEN Herbst It requires minimal cooperation. It promotes patient acceptance because it is not visible and it produces an immediate improvement in the profile. It allows more cases to be treated without extractions. It is easy to construct, fit, adjust, and clean. Materials are inexpensive, and breakage is minimal after a modest amount of laboratory experience is gained. The lower splint increases anchorage, thus providing more of a skeletal correction, and restricts forward movement of the lower incisors

The Edgewise Herbst Appliance

 The Edgewise Herbst Appliance corrects Class II

malocclusions rapidly and without the need for patient cooperation. It allows orthodontic tooth movements during orthopedic correction and a smooth transition from Herbst treatment into the edgewise finishing appliance. The new appliance is more clinically efficient than previous models and is easily incorporated into an edgewise practice.

Herbst With Mandibular Advancement Locking Unit

Components 2 tubes 2 plungers, 2 upper Mobee hinges with ball pins 2 lower key hinges with brass pins

In the upper arch of the edgewise-Herbst MALU appliance, only the first molars are banded, with .051" headgear tubes. A palatal arch can be used in cases of overexpansion.

In the lower arch, the first molars are banded, and the anterior segment is bonded from cuspid to cuspid with .022" brackets. The bicuspids may be left unbracketed to help in settling the occlusion and locking in the mandible. The mandible can be progressively advanced using 1-5mm spacers.

 Advantages:

1. Its cost is considerably lower because it requires no laboratory construction. 2. Its simplicity makes it useful even for nongrowing patients in whom only dental movement and mandibular repositioning are

required.
3. It can also be used in growing patients who have not cooperated with removable appliances

or headgear.

Flip-Lock Herbst Appliance

A new design, the Flip-

Lock Herbst appliance, reduces the number of moving parts that can lead to breakage or failure. It is easy to use and more comfortable for the patient than the conventional cantilevertype Herbst. Instead of a screw attachment, it has a ball-joint connector, and it needs no retaining springs.

 The first generation was made from a dense polysulfone plastic but breakage occurred because of the forces generated within the ball-joint attachment

 In the second generation, the plastic was replaced with metal

 The third generation is made of a horse-shoe ball joint .

This system has proved

to be more efficient than the previous models, both in terms of application as well as its resistance to fracture

End of rod is crimped onto mandibular ball.

Advantages : Less irritation reduces the number of moving parts that can lead to breakage or failure

The Jasper Jumper :

This interarch flexible force module allows patient

greater freedom of mandibular movement than is possible with the original bite jumping mechanism of Herbst. Dr. James Jasper in 1987

 Force Module : The force module, analogous to the tube and plunger of the Herbst bite

jumping mechanism and is flexible. The force module is constructed of stainless steel coil of spring attached at both ends to stainless steel end caps in which holes have been drilled in the flanges to accommodate the anchoring unit. This module is surrounded by an opaque poly urethane covering for hygiene and comfort.

 The modules are available in seven lengths ranging from 26 to 38 mm in 2 mm increments.

They are designed for

use on either side of the dental arch.

Principle of action :
When the force module is straight, it remains passive. As the teeth come into

occlusion the spring of the force module is curved axially producing a range of forces from 1 to 16 ounces.

 If properly installed to produce mandibular

advancement, the spring mechanism is curved or activated 4 mm relative to its resting length, thus storing about 8 ounces (250g) of potential for force delivery.
If less force is desired (eg force levels that produce

tooth movement alone), the jumper is not activated fully.

Increasing the activation beyond 4 mm does not

yield more force from the module but only builds excessive internal stress.

 Anchor units :

A number of methods are available to anchor the force modules to either the permanent or mixed dentitions.

 Attachment to the main arch wire :

Dr. Jasper `s method.

When the jumper mechanism

is used to correct a class II malocclusion, the force module is attached Posteriorly to the maxillary arch by a ball pin placed through the distal attachment of the force module.

The module is anchored

anteriorly to the lower arch wire (0.018x 0.025 or 0.0x0.025 ).

 Bayonet bends are placed distal to the mandibular

canines and a small Lexan ball is slipped over the archwire to provide an anterior stop. The mandibular archwire is threaded through the hole in the anterior end cap and then ligated in place. The first and second bicuspid brackets are removed to allow the patient greater freedom of movement.

Disadvantages : Unattached bicuspids tend to

erupt above the occlusal plane as the anterior teeth are intruded.
When only the lower 1st

bicuspid bracket used to be removed as originally suggested by Dr. Jasper, Jaw opening used to be limited as the lower portion of the jumper tends to bind at the 2nd bicuspid.

 Replacement of a broken jumper required

removal of the entire archwire.

If an arch breaks or comes untied at the

distal tieback, all the force is transferred to the anterior teeth, which tends to tip them forward depress them and open space.
Removing the Jumper for an occlusal check

is time consuming.
In an extraction case, it is difficult to close

spaces because the jumper must be attached to the arch before closing loops.

2. Dr. Copes Method :

Dr. Don cope makes an

attachment out of an 0.017 x 0.025 stainless steel wire, soldered to a rocky mountain lock, then bent so as to pass distal to the lower first molar. The lock is attached between the bicuspid and cuspid

 An alternative is to place the lock distal to the molar bracket with the wire bent

distal to the cuspid. The approach uses a free sliding quick connect (figure). The wire runs parallel to the main archwire, allowing the jumper to clear the bicuspid brackets.

 Advantages The attachment can be made in the office laboratory, and placement can be delegated to an assistant. The jaws can open fully. Force is directed distal to the molar; if the archwire breaks there is no effect on the anterior teeth. The jumper does not interfere with space closure or leveling procedures. A broken jumper is easy to replace. No auxiliary tubes are needed on the mandibular molars.

 Disadvantages : Laboratory time is required to solder and bend the attachment. The rocky mountain lock assembly is an additional expense.

2) Attachment auxiliary archwire :

Incorporates the use of out

rigges which are 0.016 x 0.022 (0.018 slot) or 0.018 x 0.025 (0.022 slot) auxiliary sectional wires.
The sectional arch is looped

over the main archwires anteriorly between the first premolar and canine.
Posteriorly into the lower first

molar band.

 The sectional archwire must have

adequate clearance from the alveolus and gingiva to avoid tissue impingement.
Advantages : Has all of the previous said advantages plus The clinician may leave the premolar bands in

place Materials are in expensive.

Attachment in the Mixed dentition

The maxillary attachment is as the original attachment. The mandibular attachment includes an archwire that extends from the brackets on the lower incisors, posteriorly to the first permanent molars, by passing the region of the deciduous canines and molars.

In a mixed dentition patient the use of a transpalatal arch and fixed lower lingual arch is mandatory to control potential unfavorable side effects.

 Divided into 3 phases as advocated by Dr.

Jasper
Leveling and anchorage preparation Period of jasper jumper use (6-9 months) Period of finishing (12 months)

Leveling and anchorage preparation

Alignment of the maxillary and mandibular anterior teeth during the initial phases of orthodontic treatment must be completed. Full-sized (or nearly full-sized) archwires should be inserted into the brackets in both arches before the placement of the force

modules.

The archwires should be tied or cinched back posteriorly to increase anchorage, including

second molars whenever possible.

In addition, the clinician can place posterior tip-back bends in the mandibular archwire to enhance anchorage.

 Anterior lingual crown torque can be placed

in the arch wire. Alternatively lower incisor brackets with 5 degrees of lingual crown torque incorporated into the slot also can be used to prepare anchorage.

 Preparation of the arches :

After the full sized arch wires have become

passive, the mandibular arch wire is disengaged and the brackets on the 1st and 2nd premolars are removed bilaterally.
placed in the archwire distal to the lower canine bracket, and 3 mm Lexan beads are slipped over the ends of the arch wire and moved forward to rest against the bayonet bends bilaterally.

Unless on triggers are used, bayonet bends are

Selection and installation of the modules

Determination of proper length of force module. Twelve millimeters are added to measurement of distance

between mesial aspect of facebow tube and distal aspect of Lexan ball. In this example, distance from ball to face-bow tube is 20 mm. Thus 32 mm module should be selected.

 The lower arch wire in threaded through the hole in the anterior end cap of the force module, ligated in place and the ends of arch wire are cinched or tied back firmly. Then the ball pin is inserted through the face bow tube on the maxillary first molar band from distal to mesial and cinched forward. In-patients with high mandibular plane angle the pin is cinched to achieve approximately 2mm of module deflection (150g / side). In patients with low or normal mandibular plane angle, the ball pin is cinched forward to achieve 4 mm of module deflection (300g force/ side).

 The patients are coached to practice opening and

closing movements slowly at first and told to avoid excessive wide opening during eating and yawning.

Activation of the module for orthodontic and orthopedic effect :

If molar distalization is desired. The jumper is placed so that only 2-4 ounces of force is produced by the module. In growing patients in whom orthopedic repositioning of the mandible is desired, higher forces (6 - 8 ounces) are used continuously.

Reactivation of the module :

If the class II molar relationship is not corrected completely by the initial activation, the modules

should be reactivated 2 3 months later.

The pin extending through the face bow is pulled anteriorly 1-2 mm on each side to reactivate the module. 2-4 mm of the pin should extend distally when the pins are activated maximally (so that the jumper does not blind against the distal aspect of the face bow tube.)

Ball pin protrudes 2-3mm distally, allowing free movement. B. Ball pin too close to molar tube, which can cause breakage of ball pin or Jumper. C. Correct placement. Anterior force is delivered distal to lower molar bracket, while depressing force is delivered to archwire between cuspid and bicuspid.

 Activation of the force module can also

be made by crimpable stops (1 2mm) placed mesial to the lexan beads.

It is more accurate Easier to perform Avoids unintentional restriction of ball

pin / molar tube relationship

 Types of forces

produced :

Bilateral directions of

force generated by the modules include sagittal, intrusive and expansion forces.

Force module curves to buccal, producing shielding effect on

dentition.

 Buccal force due to intrusive force acting

along the buccal surfaces of the maxillary teeth produces maxillary arch expansion. Modules curving outwards Vestibular shielding effect
Expansion forces can be minimized or

eliminated through the use of a transpalatal arch or a heavy arch wire that has been narrowed and to which buccal root torque has been applied.

Treatment effects :
Maxillary adaptations : i) Headgear effect :
One treatment effect produced most easily is

distalization of the upper posterior segment or the headgear effect. For this the maxillary arch wire must not be cinched or tied back, but remain straight and extend past the buccal tubes. Involves light forces (2-4 ounces) Minimal changes in the mandibular dentition. This effect can be produced in actively growing as well as adult patients.

Retraction of anterior teeth

Upper canines alone or all the

six anterior teeth can be retracted in both extraction and non-extraction patients with a NiTi coil or an intramaxillary elastic, with the posterior maxillary dentition supported by the force module.
Cuspid retraction mechanics: As Jumper pushes ball pin distally, molar anchorage is maintained and cuspid is retracted along archwire.

 Maxillary anterior teeth are

retracted as a unit by attaching ligature to appropriate archwire tiebacks.

Dental Asymmetries
The force module system also can be

used in-patients who have sagittal dental asymmetries. In a patient with a class II subdivision type of malocclusion the maxillary archwire orthopedic effects may also be achieved. Asymmetric orthopedic effects may also be achieved

Mandibular Adaptations :
In producing mandibular advancement

the movement of maxillary posterior dentition must be cinched or tied back.

Also a transpalatal arch must be placed,

to obtain intra arch anchorage.

Level of force generated is higher (6 to 8

ounces ) than for headgear effect.

 Jaspers theory of twos suggests that class II correction with Jasper jumper therapy can be equally proportioned between 5 components.
1. 20% due to maxillary basal restraint 2. 20% due to backward maxillary dent alveolar movement 3. 20% due to forward mandibular dentoalveolar movement 4. 20% due to condylar growth stimulation 5. 20% due to downward / forward glenoid fossa remodeling

 Nalbantgil D, Arun T, Sayinsu K, Fulya I Angle

Orthod 2005 studied 15 subjects (class II) treated with jasper jumper and compared them with15 untreated(class II) subjects. They were late adolescent patients.
Results: Class II discrepancies were mainly corrected by dentoalveolar changes and this could be an alternative method to orthognathic surgery in borderline class II cases.

MARS Appliance
(Mandibular advancing repositioning splint).

This appliance was introduced by Ralph M Clements and Alex Jacobson.1982

The MARS appliance is composed of a pair of telescopic struts, the ends of which are attached to the upper and lower archwires of a multi-banded fixed appliance by means of locking device.

 The Piston fitted to

the cylinder of a MARS appliance.

 Alignment must be complete.

The teeth in the respective arches should be aligned, with correct axial inclinations, prior to attachment of the appliance. The MARS appliance should be attached only to the heaviest rectangular arch wires that can be accommodated by the brackets and tubes. The heavy arch wire prevents breakage at the point of attachment as well as excessive intrusion in the region of the mandibular canines. The mandibular arch wires should be securely tied back to the terminal molar before attachment of the MARS appliance.

Failure to do this will usually result in flaring of the lower incisors, even with the heavy rectangular arch wire, since the untied arch wire will slide forward through the tubes and brackets of the posterior teeth. Previously closed mandibular extraction spaces are likely to reopen if this precaution is not taken.

Determining length of assembly

With the patients protruding the mandible into a class

I position, the right and left strut lengths are measured. Tube attached most mesially on the last molar incorporated and most distally to mandibular canines.

The MARS strut length is that distance from the

middle of the interbracket space distal to the lower canine to the middle of the interbracket space mesial to the maxillary terminal molar.

 The upper member or hollow tube length is determined

by subtracting a calculated and standardized measurement of 7.4mm from the strut length.

The free end of the lower member or the plunger is then

cut so that 2mm extends out of the back of the upper member

One reference measurement needed for this appliance

is the PIED (Protrusive incisial edge distance) PIED is the horizontal distance measured at the midline between the maxillary and mandibular incisial edges with the mandible in its maximum strained protruded position.

The MARS appliance should be locked into position with the mandible 2 to 3 mm posterior to the maximum PIED measurement. In the event a patient encounters muscular discomfort as a result of protruding the mandible too far forwards the appliance is adjusted and locked in a less protrusive position. At subsequent appointment the PIED should be measured and recorded. The authors have observed that the PIED will increase from 0.5 to 2 mm between 3 to 4 week appointment intervals. When the PIED ceases to increase between appointments, the MARS appliance is then adjusted so that a super class I occlusal relationship is obtained.

 Two methods to lengthen the appliance

1) Replacement of the struts with longer upper members of cylinders. 2)Placement of spacers 2 to 3 mm in length on the lower members or pistons.

Unlike the Herbst appliance, the MARS appliance : Requires neither soldering nor extensive lab procedures. Has minimal incidence of breakage Does not depress the canines, open spaces in the premolar area or flare mandibular incisors (provided the mandibular rectangular archwire is tied back to the terminal molars) Is easily removed.

 Disadvantages : Need for a fixed multi-banded appliance limits its

use in mixed dentition cases.

Disarticulates at the posterior segments from 1 to 3

mm
Need to customize the appliance for each patient.

Mandibular Protraction appliances :

This appliance was developed by Carlos Martin Coelho Filho (JCO 1995). His inability to purchase some of the newer class II corrective appliances in northern Brazil led him to develop these group of appliance that reposition the mandible forward.

 They have proven effective in treating Class I patients

with exaggerated overjets and Class II subdivision patients where only one side needs correction. Their advantages include ease of fabrication, low cost, infrequent breakage, patient comfort, and rapid installation.
But they are not claimed to be superior but are only

treatment alternatives to Class II therapies.

 Each side of the appliance is made

by bending a small loop at a right angle to the end of an .032" stainless steel wire. The length of the appliance is then determined by protruding the mandible into a position with proper overjet, overbite, and midline correction and measuring the distance from the mesial of the maxillary tube to the stop on the mandibular archwire.

Another small right-angle circle is then bent in an opposite direction into the other end of the .032" stainless steel wire. The angulation of these circle bends can vary to allow free sliding along the mandibular archwire. One appliance circle is placed over the maxillary archwire against the molar tube, and the other circle against the mandibular archwire stop. Both circles are then closed completely with a plier.

Functioning of the appliance MPA -1

Appliance slides distally along mandibular archwire and mesially along maxillary archwire upon opening. But frequent dislodgment of molar bands led Filho to develop the 2nd protraction appliance. (MPA n.o 2)

MPA No. 2
MPA No. 2 is made with right-

angle circles in two pieces of .032" stainless steel wire. Coil of .024" stainless steel wire is slipped over one wire. Travel of each wire is limited by wire coil.

Improper relationship of wires is prevented by coil.

Maxillary archwire has occlusally directed circles against molar tubes; mandibular archwire has occlusal circles 2-3mm distal to each cuspid.

Advantages :
Easily fabricated at chair side, with

ordinary inexpensive wires.

Do not require any special bands ,

crowns or wire attachments. registrations are needed.

No impression or wax bite

Easily inserted adjusted,removed and

can be made and installed in about 30 minutes.

Much smaller and thus more

comfortable.

Permit a greater range of motion and

are less restrictive of movement

MPA-3
CARLOS M. COELHO FILHO,(JCO

2001)

Many of the limitations of the

first two MPA designs have been overcome with the development of the MPA No. 3.
This version eliminates much of

the archwire stress and permits a greater range of jaw motion while keeping the mandible in a protruded position.

Appliance construction
The parts needed for the

construction of the MPA No. 3 are: internal diameter each about 27 mm long. stainless steel wire, each about 13 mm, long, with a loop bent into one end at an angle of about 130 to the horizontal. stainless steel each about 27 mm long.

Two maxillary tubes of 0.045

Two maxillary loops of 0.040

Two mandibular rods of 0.036

Annealed pin bent mesial to the molar tube

MPA No. 3 reversed for Class III treatment, with open-coil spring between appliance tube and rod loop.

Advantages of MPA n.o 3 over the previous models :

More comfortable for the patient Offers greater range of motion Equally simple and inexpensive but easier to place Adaptable to either class II or class III cases Can be used for mandibular positioning or dento alveolar movement Causes less breakage.

MPA IV
The latest version, the

MPA IV,** is much easier to construct and install, and much more comfortable for the patient. The MPA IV is made up of the following parts:

T tube Upper molar locking

pin Mandibular rod Mandibular archwire

Piece of .040" stainless steel wire is inserted into longer tube to prevent deformation while bending molar locking pin with finger pressure.

Molar locking tube is then cut and annealed to make it easy to bend during installation.

Mandibular rod inserted into T tube.

This fourth version seems to be as efficient as its antecedents, but is much more practical to construct, easy to manipulate, and comfortable for the patient.

Adjustable Bite corrector (ABC) (JCO 1995)

Introduced by Richard P. West

The appliance essentially consists of:

A stretchable closed coil spring and internally threaded end cap nickel titanium wire in the centre lumen of the spring. The closed coil spring is made of

0.01 8 stainless steel, and will stretch to about 25% beyond its original length without permanent deformation.

The ABC can be used on either side of the mouth with a simple 180 rotation of the lower end cap to change it orientation.
Functions similar to the Herbst and Jasper Jumper but also incorporates several useful features like a) Universal right and left b) Adjustable length and force

 After the patient has postured

forward into an improved profile with ideal overbite / overjet the point of the gauge is placed into the mesial opening of the headgear tube. The size is then read at point about 3mm below the contact between lower cuspid and first premolar using the correct appliance size ensuring optimum force delivery.

 Nickel titanium wire is

replaced and end caps unscrewed to add appliance length.

 Repairs and emergencies :

Wire fractures are infrequent with the ABC.

Repair is easy, where the end caps are unscrewed and

the coil spring or nickel titanium wire is replace with a new one from the kit.

 The ABC can be used for upper molar anchorage

control during retraction of anterior teeth for space closure.

The class II push force of the ABC creates full time

maximum anchorage at the upper molars while bringing the lower posterior teeth forward form the pull at the jig attachment.

The Eureka Spring (JCO 1997)

Introduced by John De Vincenzo The main component of the Eureka

spring is an open wound coil spring encased in plunger assembly The ram is made from a special work hardened stainless steel that has been precision machined with 3 different radii. At the attachment end the ram has either a closed or an open ring clamp that attaches directly to the archwire.

The essential aspects include spring module A, molar attachment tube B, push rod C, free distance D, molar attachment wire E, free distance F.

 A triple telescoping action permits the mouth to open as wide as 60 mm before the plunger becomes disengaged.
The cylinder assembly is connected to a molar tube with a an 0.032 wire that has been annealed at the anterior end. An 0.036 solid ball at the posterior end acts as

a universal joint, permitting lateral and vertical movements of the cylinder.

The Eureka spring comes in only 2 sizes one for extraction and one for non-extraction cases and left and the right sides are interchangeable.

Advantages
It has esthetic acceptability because of its small size and

lack of protuberances into the buccal vestibule, as it is almost invisible.

Resistance to breakage: produces forces of only 140g-170g

at the points of attachment as compared to 220-280g of Jasper Jumper. Ability to produce rapid movement : this is in spite of its low force levels because the Eureka spring continues to work even when the mouth is opened as much as 20 mm as when sleeping or when the mandible is thrust forward as far as 10 mm, in an attempt to minimize the force.
Ease of installation

No auxiliary archwires or extra impressions for laboratory

fabrication are needed.

 Low cost : similar in cost to the jasper jumper but less expensive than the fixed Herbst appliance.

Minimal inventory requirement

Optimal direction of force Delivers a push force against mandibular anterior

and maxillary posterior teeth.

It also has a vertical intrusive component at the maxillary molars and mandibular although this is minimal due to direct archwire attachment, rather than via auxiliary wire.

The churro jumper (JCO 1998)

Introduced by Ridhardo Castanon, Mario S Valdes and Larry White. The Churro Jumper furnishes orthodontists with an effective and inexpensive alternative force system for the anteroposterior correction of class II and class III malocclusions. It was developed as an improvement of the MPA of Coelho. Although the churro jumper was conceived as an improvement to the MPA, it functions mere like a Jasper Jumper.

Construction :
The Churro Jumper requires a

series of 15-20 symmetrical and closely placed circles, formed in a wire size of .028" to .032".
Since the Churro Jumper

requires reciprocal anchorage, Generally, the largest possible edgewise archwire is the best to use. This will usually be an .018" X .025" archwire, or .0175"X .025". Any wire smaller than these invites breakage.

 Churro needs space to slide on

the mandibular archwire, at least the first premolar brackets should be omitted. It is usually advantageous to place a buccal offset in the wire just distal to the canine bracket so that the jumper also has buccal clearance, which permits unrestricted sliding along the wire

The length of the jumper is determined by the distance from the distal of the mandibular canine bracket to the mesial of the headgear tube on the maxillary molar band, plus 1012mm. This measurement is transferred to the Churro Jumper, with the coil closer to the canine bracket than to the headgear tube.

Mode of action :
In its passive form, the churro is not flexed However when the pin is pulled forward enough to cause the jumper to bow outward the cheek, the appliance begins to exert a distal and intrusive force against the maxillary molar and a forward and intrusive force against the

incisors as it attempts to straighten.

Unilateral / Bilateral use :

This jumper can be used unilaterally in cases of class II subdivision malocclusions.

The bilateral class II churro jumper is most suitable for patients who need mandibular incisors advancement. Not a very good choice for class II bimaxillary proclination cases.
By reversing the attachments, the churro jumper can also be used to treat class III malocclusions.

Advantages :
Provides a constant, indefatigable force. Can be used either unilaterally or bilaterally. Can be used in class II or class III cases. Helps maintain anchorage. Very inexpensive. Can be constructed from commonly available materials universal in size. When broken, it is easily replaced. Staff members can quickly learn how to replace an appliance.

Disadvantages :
Restricts the mouth opening to 30-40 mm Archwire breakage is seen if larger wires not used. Patients with a low tolerance for discomfort will often break the appliance. Patients who incessantly move their mouths while

chewing, talking and nervous tics will fare poorly. Its maximum effectiveness depends on a permanent dentition to retain its effect. It must be manufactured in the office.

The universal bite jumper (JCO 2001)

Introduced by Xavier Calvez

This is a fixed functional which

can be used in all phases of treatment, in the mixed or permanent dentition and with removable or fixed appliances.
This jumper also uses a

telescoping mechanism, can also have an active coil spring if necessary.

Fixed appliance configuration

In the mandibular arch, the sliding rod ends in a 90 hook that is fixed to the archwire.

UBJ ATTACHED TO AUXILLARY WIRE

Lower cantilever configuration

The UBJ tubes are welded to the maxillary molar bands or crowns. . The UBJs are adjusted while mandibular movements are checked. Depending on the case, the brackets can be bonded during the

same visit or a few weeks later. The advantage of this configuration is the possibility of immediate orthopedic action without waiting for dental alignment.

Removable splint mounting

When used with removable acrylic splints, two lateral UBJs

link the maxillary molar areas and the mandibular first premolar areas. They are attached to 1.2mm ball clasps, which are constructed on the working cast and then incorporated into the thermoformed splints.

Single median UBJ

A single median UBJ can be used to link the removable

splint from the middle rear area of the palate to the lingual surface of the mandibular incisor.

The UBJ is attached to two transverse axles, which allow opening and lateral

movements.

 The median UBJ provides muscular therapy as it

prevents the tip of the tongue from contacting the lower lip. appliance, given a little time to adjust. Cheek impingement is eliminated and it is the authors experience that the tongue is not irritated with this design.

Most children are able to speak well with this

Adjustments :
Reactivation are made every 6 to 8 weeks by crimping 2 to 4 mm splint bushings on to the rods. Midline or asymmetrical problems can easily be treated by adjusting one side or other of the appliance.

Advantages
It is simple, sturdy, and inexpensive. Inventory requirements are minimal--the UBJ can be used on either side of the mouth, and there is only one size, since it is cut to the desired length for each case.

It can be used at any stage of treatment --in the early mixed dentition to obtain an immediate mandibular advancement before any dental alignment, or in the permanent dentition for fixed functional treatment.

 It can be used in Class II or Class III cases. Its low profile results in considerably less buccal irritation than with similar appliances. Patient comfort and acceptance are excellent. It can easily be attached to removable splints for maximum anchorage. It produces good results without the need for patient cooperation

The saif Spring

(Severable Adjustable inter maxillary force)

First interarch force system developed by Armstrong In the later 1960s and early 1970s he introduced the Pace Spring, later termed multicoil spring and finally called Saif spring.
These were first marketed by North West orthodontics, later by Unitek, and currently by Pacific coast manufacturing.

They consist of two springs one inside the other with soldered loops on each end.

 Various attachments can be placed through these loops

to secure the springs to deliver either class II or class III force. outside diameter of 3 mm, and deliver 200 to 400 gms of force.

They are available in 7 mm and 10 mm lengths, have an

Breakage is a constant problem. Bit bulky, not very hygienic and there is some limitation

to mandibular opening

However large forces are generated by these springs

which may account for the surprisingly rapid correction observed.

The Ritto Appliance

The Ritto Appliance can be described as a miniaturized telescopic device with simplified intraoral application and activation

 Fixation accessories

consist of a steel ball pin and a lock.

Upper fixation is carried

out by placing a steel ball pin from the distal into the .045 headgear tube on the upper molar band, through the appliance eyelet and then bending it back on the mesial end.

 The appliance is fixed onto a prepared lower arch and is activated by sliding the lock along the lower arch in the distal direction and then fixing it against the Ritto Appliance.

The Magnetic Telescopic Device

Ritto A.K. in 1997 This consists of two tubes and two

plungers with a semi-circular section and with NdFeB magnets placed in such a manner that a repelling force is exerted.
MALU system.

Fitting is achieved by using the This appliance has the advantage of

linking a magnetic field to the functional appliance. Its main disadvantages are its thickness, the laboratory work necessary to prepare it and the covering of the magnets.

THE TWIN FORCE BITE CORRECTOR

This appliance differs from others

in form and constitution because it has two internal coil springs. It consists of two joint telescopic systems. At the superior level it is fixed with a ball pin that is fitted into the buccal tube of a molar band. The placement in the lower arch is slightly different; it involves a fitting-in system that is later fixed with a screw to the inferior arch. Normally it is placed distal to the lower cuspid.

 Drawbacks:
The major drawback of this appliance is the

difficulty to control the force. May create discomfort and impingement problems. Is recommended only for permanent dentition.

ALPERN CLASS II CLOSERS

It is one of the most recent. It is predominantly applied in

Class II correction and as a substitute for elastics. It consists of a small telescopic appliance with an interior coil spring and two hooks for fixing It functions in the same way as elastics and, similarly, is fixed to the lower molar and to the upper cuspid. It is available in three different sizes. Its telescopic action enables a comfortable opening of the mouth.

Mandibular Corrector (JCO 1985)

Introduced by Marston Jones It is a fixed functional that uses

bilateral piston and plunger telescopic mechanism to reposition the mandible anteriorly and is directly attached to archwires of a multibanded fixed appliance.

Connectors holding the repositioning arms are attached

to the archwires distal to the lower cuspid brackets and mesial to the tubes on the terminal upper molars.

 The length of the repositioning arms are determined

intraorally with the patients mandible advanced 3-4 mm. The entire procedure can be completed at chair side in 30 minutes. The mandible can be advanced in small increments of 2-4 mm at 4 week intervals until the incisors are in an edge to edge relationship. Midline corrections are made by advancing the appliance more on one side. A correction of 3-4 mm can be achieved within 6 months, an overjet of 7 to 8 mm may require 12-14 months.

The Horizontal Anterior Positioning (HAP) appliance

Most of the appliances have

anterior contact while allowing for posterior eruption. Unfortunately, the lack of posterior support has been shown to have a loading effect on the TMJ.
Dr. William B. Farrar recognized

the need for posterior support and modified the original Sved appliance to incorporate two posterior acrylic pads along with an anterior ramp.

Components of HAP appliance: A. Anterior reverse ramp. B. Sagittal screws. C. Expansion arms. D. Coffin spring. E. Locking mechanism.

Anterior reverse ramp

Expansion arms Sagittal screws

Locking mechanism

Coffin spring

 A lower "dipod, which

provides upper and lower posterior occlusal support. A posterior pad can be added to the HAP, but adjustments become more difficult and the possibility of breakage increases. The vertical dimension can be increased if necessary. The bite-opening effect allows for passive or active eruption of the posterior occlusion to help level the curve of Spee.

The Mandibular Anterior Repositioning Appliance(MARA)

These interferences are produced when a horizontally adjustable vertical bar attached to the buccal surface of a maxillary first molar stainless steel crown, hits a buccally protruding horizontal bar extending from the lower first molar stainless steel crown. Additional activations can be made by placing one or more shims at the mesial aspect of the horizontal bar. Advancing the mandible forward in precise increments can be achieved by insertion of selected shims of varying

 Advantages over Herbst

Better esthetics Problem with disengagement do not occur Breakage from lateral mandibular movements should be less. Can be used concurrently with full edgewise

orthodontic appliance. This

Eliminates the need for a 2 phase treatment. Can maintain the achieved orthopedic results, since the

appliance can continue in a non activated manner.

 Disadvantages
Temporary stainless steel crowns needed on all first molars.

Some increase in anterior facial height results from the placement of these crows.
Fabrication only available at one commercial

laboratory. The posterior and buccal location of the guide planes may cause loosening of the stainless steel crowns or breakage of the mandibular protruding horizontal bar.

Functional Mandibular Advancer

Kinzinger,Ostheimer, Diederich,2002 It has a propulsive mechanism that

resembles the Mandibular anterior repositioning appliance, but differs in its mode of action and intraoral activation. It relies on the principle of inclined planes that are placed in the buccal corridor spaces that will not hinder swallowing or articulation. The protrusion guide pins are fitted to the upper portion of the apliance at a 60 degree angle to horizontal, ensuring active, forward mandibular guidance during even partial jaw closure.

 Reactivation in the sagittal plane

is done simply by moving the guide pins to a more forward threaded support sleeve. This gradual activation allows patients particularly adults to adjust to the appliance.
Kinzinger, Diederich JCO 2005

reports the use of FMA in a 16 year old male with Class II div2 and for just 3 months the patient was able to protrude the mandible significantly forward from the therapeutic position.

Advancement in therapeutic positions

Maximum protrusion of mandible after 3 months

The Biopedic
Designed and introduced by Jay

Collins in 1997 (GAC International) soldered to maxillary and mandibular molar crowns.

It consists of buccal attachments

The attachments contain a standard

edgewise tube and a large 0.070 inch molar tube. Large rods pass through these tubes. mesial of the molar tube and is fixed at the distal by a screw clamp. By moving the rod mesially the appliance is activated.

The mandibular rod inserts from the

 This short maxillary rod is inserted screw at the mesial of the maxillary first molar.

The two rods are connected by a rigid shaft and have pivotal region at their ends.
Although, it appears that there would be limitation of mandibular opening, it is not so. The design works more in harmony with the arc of mandibular opening.

 Advantages
Can be used concurrently with banded treatment.

Esthetic benefit
Capability of adjusting the amount of protrusive activation. Disadvantages Potential for more breakage and loose crowns Greater cost. Need for crowns on molars

 Introduced by Lewis Klapper in

The Klapper Superspring II

1997, for correction of class II malocclusions. On first glance, it resembles a Jasper Jumper with a substitution of a cable for the coil spring. In 1998 the cable was wrapped with a coil and the Klapper superspring II was the result. Only two sizes are required (left and right sides are not interchangeable) and breakage is less frequent. However it differs significantly from the Jasper Jumper at the molar attachment.

 The SUPERspring II is a flexible spring element that attaches between the maxillary molar and the mandibular canine. It is designed to rest in the vestibule, making it impervious to occlusal damage and allowing for good hygiene. Only minor adjustments are needed for patient comfort, without any impingement on soft tissues.

Disadvantages

Requirement of a special molar tube Lack of adaptability to correct class III conditions Limitation to maximal opening Potential injury to the patient if breakage occurs and the rigid molar attachment forces the broken portion into the soft tissues.

Forsus Fatigue resistant Device

This is an interarch push

spring which produces about 200g of force when fully compressed.

The distal end of the FRD`s

push rod inserts into the telescopic cylinder and a hook on the mesial end is crimped directly to the archwire near the canine or premolar brackets.

 The push rod has a built in

stop that compresses the spring when the patients mouth closes. The spring is then transferred to the maxillary molars using the mandibular arch as the anchorage unit. eyelet of the telescoping spring and is threaded through the molar headgear tube from distal to mesial and cinhed,leaving 2mm slack.
over the mandibular arch wire and crimped shut.

The L-pin is inserted in the

The mesial hook is looped

 Advantages: It does not require time-consuming and expensive lab work or the use of stainless steel

crowns. It produces consistent treatment results in a predictable amount of time, without depending on patient cooperation. It can deliver an orthopedic effect to both jaws or more of a dentoalveolar effect. It can be activated more on one side than on the other, so it excels at correcting midline deviations.

 William Wogt JCO June 2006 reports a case where a 12 year old male with class II division 1 and moderate overjet of 7mm was corrected with the Fatigue resistant device in 6months after which it was used as an anchorage unit for the retraction of the maxillary anterior segment.

Conclusion :
Fixed functional appliances form an useful

addition to the clinicians orthodontic armamentarium. But many of these appliances need further studies to substantiate the claims made by their respective originators. With this in mind, clinicians must take great care in selecting the right patient and also pay attention to every detail in the manipulation, to attain successful results with these appliances.

ferences:
1.

Larry.W. White :Current Herbst Appliance Therapy:JCO 1997,May(296 - 309) Arji George, V. Surendra Shetty, SN Rao & Ashima Valiathan: Effect of Herbst appliance on Orofacial musclature. Journal of Indian Orthodontic Society. 1993; 4(3): 93-99.

2.

3. S.Jay Bowman: Jasper Jumper in Class II correction. A case report. JIOS 2001;34:101-105.

4.

5.

Kinzinger, Oestheimer, Deidrich: Development of a new fixed functional appliance for treatment of skeletal class II malocclusion.J. Orofac Orthop 2002 63:384399 Ken Hansen: Treatment and posttreatment effects of the herbst appliance on the dental arches and arch relationships. Semin Orthod 2003 March,page 67-73

6. Kinzinger, Deidrich: Bite jumping with the functional mandibular Advancer, JCO December 2005 page 696-700 7. Carlos Martins Coelho Filho,Mandibular Protraction Appliances for Class II Treatment

Volume 1995 May(319 - 336)

8. Klapper L, The Super spring II: A new appliance for non-compliant class II patients.

J. Clin. Orthod. 1999; 33: 50-54.

9. Sabine Ruf, Hans Pancherz: When is the ideal period for

Herbst therapy-Early or Late? Semin Orthod 2003,March,page 47-56

10. Mc Namara, Brudon, Kokich, Orthodontics and

Dentofacial Orthopaedics, 2001 page 285,333

11. Cope J.B., Buschang P., Cope D.D., Parker J., Blackwood

H.O. Quantitative evolution of craniofacial changes with Jasper Jumper Therapy. Angle Othod. 1994; 64 (2): 113 122.

12. Miller R.A. The Flip-lock Herbst Appliance. J. Clin. Orthod. 1996; 30: 552 58. 13. Jasper J.J., McNamara J. The correction of interarch malocclusions using a fixed force module. Am. J. Orthod. Dentofac. Orthop. 1995; 108: 641-50.
14. Pancherz H. Treatment of Class II malocclusions by jumping the bite with the

Herbst appliance. A cephalometric investigation. Am. J. Orthod. 1979; 76: 423442

15.

Heinig N, Goz G: Clinical application and effects of the Forsus spring. A study of a new Herbst hybrid, J Orofac Orthop. 2001 Nov;62(6):436-50.

16. Pancherz H. The mechanism of Class II correction in Herbst appliance treatment. Am. J. Orthod. 1982; 87: 1-20. 17.

Pancherz H. The Herbst appliance Its biological effects and clinical use. Am. J. Orthod. 1985; 87: 1-20.

18. Erdogan E. Asymmetric Application of the Jasper

Jumper in the correction of midline discrepancies. J. Clin. Orthod. 1998; 32: 170 80. 19. Sabine Ruf:Short and Longterm effects of the Herbst appliance onTemporomandibular joint function,Semin Orthod 2003 March page 74-86. 20. Cash R.G. Case Report: adult nonextraction treatment with a Jasper Jumper. J. Clin. Orthod. 1991; 25: 43-7..

21. Castaon R., Valdes M., White L.W. Clinical use

of the Churro Jumper. J. Clin. Orthod. 1998; 32: 731 45.

22. Blackwood H.O. Clinical Management with the

Jasper Jumper. J. Clin. Orthod. 1991; 25: 755-60 23. Haegglund P. The Swedish-Style Integrated Herbst Appliance. J. Clin. Orthod. 1997; 31: 378 390.

24. Pangrazio-Kulbersh V, Berger JL, Chermak DS, Kaczynski R, Simon ES, Haerian A:Treatment effects of the mandibular anterior repositioning appliance on patients with Class II malocclusion. Am J Orthod Dentofacial Orthop. 2003 Mar;123(3):286-95 25.

Calvez X. The universal bite jumper. J. Clinical Orthod. 1998; 32: 493-499.

26. Filho C.M. Mandibular Protraction Appliances for Class II Treatment. J. Clin. Orthod. 1995; 29: 319 336.

27. Hans Pancherz :History, Background, and Development of the Herbst Appliance, Semin Orthod 2003,March page3-11 28. Filho C.M. Clinical Applications of the Mandibular Protraction Appliance. J. Clin.

Orthod. 1997; 31: 92 102.

29. Filho C.M. The Mandibular Protraction Appliance III. J. Clin. Orthod. 1998; 32: 379-384

30. Mandeep sood, k.Sadashiva Shetty: Functional therapy- Is it worth the effort? JIOS1994 October page 128-136. 31. Aidar LA, Abrahao M,Yamashita HK, Dominguez GC:Herbst appliance therapy and temporomandibular joint disc position- A

prospective longitudinal magnetic resonance imaging study. Am J Orthod Dentofacial Orthop. 2006 Apr;129(4):486-96.

32. William Vogt:The Forsus Fatigue Resistant Device, JCO 2006 June page 368-376